HIS - HEALTH INFORMATION ASST.

**JOB SUMMARY:** The Health Information Assistant’s main priority is maintaining the health records of the facility per policy and state/federal compliance regulations to ensure residents’ records contribute to the quality of care. The Health Information Assistant reports to the HIM (Health Information Manager). This position is hourly (non-exempt). **ESSENTIAL JOB FUNCTIONS**: - Assists the HIM with analyzing and evaluating medical records for in-house residents per State & Federal regulations, accepted professional standards, and facility policies and procedures to include both quantitative and qualitative auditing. - Audits new admissions and discharges promptly per procedures. - Performs quality auditing on care plans, licensed nurses notes, RAI, informed consent, PDSA; reports outstanding audits to the Director of Nursing and Administrator. - Performs Quality Audits routinely including but not limited to: Skin, Diabetic, Foley Catheter, Bowel and Bladder Retraining, Restorative Nursing, Specialized Therapy, Change in Condition, Physical Restraints, and Psychotropic drug documentation. - Sorts and scans medical documents into PCC. - Files, maintains records, release of records per rules and regulations. - Performs discharge chart process; arranges record in proper audit order; performs final audit/screening; follows up on deficiencies, closes records within 30 days of discharge. - Provides oversight and facilitates the record destruction process. - Maintains Medical Records Department/Services for the facility. - Maintains primary & secondary medical records filing systems including storage, protection, and destruction of medical records. - Maintains correspondence and medicolegal aspects of medical records. - Compiles statistics; prepares miscellaneous records and reports. - Assists physician & allied health personnel to complete medical records. - Follows up on the Physician’s Visit Control Log & Verbal Order Control. - Maintains knowledge of computer system for medical records per daily data entry of physician’s orders, new admissions and discharges - Audits and monitors timeliness of RAI for EDT on an ongoing basis. - Protect privacy and security of Health information and follows confidentiality and release of information procedures. - Responsible for any audit process assigned by the Health Information Manager **QUALIFICATIONS:** - High school diploma or equivalent preferred. - Must have knowledge of medical terminology and knowledge of clerical office practices. - Knowledge of state and federal regulations including Title XXII and OBRA preferred. - A minimum of one-year combined experience in skilled nursing or another related health care field preferred